Case 7: Physical Exam

Vital Signs: Temperature 100.0°F, Blood Pressure 118/70 mmHg, Heart Rate 108 beats/min, Respiratory Rate 20 breaths/min, Oxygen Saturation 100% on room air
General Appearance:  Anxious, ill-appearing
HEENT: Normocephalic atraumatic, no scleral icterus, dry mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: Tachycardic but regular rhythm, no JVD, no murmurs, rubs, or gallopsstethoscope
Pulmonary: Tachypneic with all lung fields clear to auscultation on exam, no wheezes, rales, or rhonchi
Abdominal: Soft but exquisitely tender in the RUQ, LUQ and epigastric areas, there is guarding but no rebound, decreased bowel sounds, unable to assess hepatosplenomegaly due to patient’s inability to tolerate the exam
Extremities: Warm and well perfused, no pedal edema
Neurologic: Alert and oriented, no focal neurological deficits
Skin: Warm, dry

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